Medical Records Authorization (HIPAA) - Kansas

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (KANSAS)

This Authorization complies with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. § 164.508, and applicable Kansas law.

1. PATIENT IDENTIFICATION

2. PROVIDER(S) AUTHORIZED TO RELEASE RECORDS

I authorize the following provider(s), facility(ies), and their business associates to release my protected health information ("PHI"):

3. RECIPIENT(S) — WHO MAY RECEIVE THE RECORDS

4. RECORDS / INFORMATION TO BE RELEASED

☐ Complete health care record
☐ Only records for the following date range: [__/__/____] to [__/__/____]
☐ Only records relating to the following incident/condition: [________________________________]

Record types (check all that apply):

☐ History and physical / office notes
☐ Physician and nursing notes
☐ Hospital / emergency-department records
☐ Diagnostic imaging (X-ray, MRI, CT) and reports
☐ Laboratory and pathology results
☐ Operative and procedure reports
☐ Physical therapy / rehabilitation records
☐ Prescription and medication records
☐ Itemized billing statements and insurance records
☐ Other: [________________________________]

5. PURPOSE OF DISCLOSURE

This disclosure is made at the request of the patient for the following purpose: evaluation, investigation, prosecution, and settlement of the patient's personal-injury claim, including legal representation.

☐ Other purpose: [________________________________]

6. HIPAA CORE-ELEMENT RECITALS

6.1 Expiration. This Authorization expires on the earlier of: (a) [__/__/____]; (b) the following event: [final resolution of the personal-injury claim]; or (c) if no date or event is stated, two (2) years from the date of signature.

6.2 Right to Revoke. I may revoke this Authorization at any time by written, signed notice to the provider, except to the extent action has already been taken in reliance on it.

6.3 No Conditioning. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether I sign this Authorization, except as permitted by 45 C.F.R. § 164.508(b)(4).

6.4 Redisclosure Notice. Information disclosed under this Authorization may be redisclosed by the recipient and may then no longer be protected by HIPAA or Kansas law.

6.5 Copy. I am entitled to a copy of this signed Authorization.

7. SPECIAL-CATEGORY RECORDS — SEPARATE SPECIFIC AUTHORIZATION REQUIRED

Part 2 warning: Initialing this general authorization does not itself create a consent that satisfies 42 C.F.R. § 2.31. Use a standalone consent containing every applicable current § 2.31 element. If the records will be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding, § 2.31(d) prohibits combining that consent with a consent for any other purpose. Each disclosure made under a valid consent must also carry one of the notices permitted by § 2.32(a) and a copy of the consent or a clear explanation of its scope under § 2.32(b).

8. COPY FEES AND RESPONSE TIME (KANSAS)

Under K.S.A. 65-4971(a), copies of health care records must be furnished to a patient or an authorized representative within thirty (30) days of receipt of the authorization, or the provider must explain in writing why copies are unavailable. The statutory per-page fee cap formerly in K.S.A. 65-4971(b) was repealed by the 2011 Kansas Legislature. With no state fee schedule, federal law controls: a covered entity may charge only a reasonable, cost-based fee for copying (supplies and labor) and postage if mailed, and may not charge for searching and retrieving the information (45 C.F.R. § 164.524(c)). A provider may withhold copies it reasonably believes would cause substantial harm to the patient or another person. Mental-health, HIV/AIDS, and SUD records require separate authorization as set out above.

9. SIGNATURE

Personal representative (if patient is a minor, incapacitated, or deceased):

10. NOTARY (OPTIONAL)

State of Kansas, County of [________________]

Subscribed and sworn before me this [____] day of [____________], 20[____].

Notary Public: ________________________________ My commission expires: [__/__/____]

SOURCES AND REFERENCES

• 45 C.F.R. § 164.508 — HIPAA authorization core elements: https://www.ecfr.gov/current/title-45/section-164.508
• 45 C.F.R. § 164.524(c) — Access; reasonable cost-based copy fee: https://www.ecfr.gov/current/title-45/section-164.524
• 42 C.F.R. Part 2 — Confidentiality of SUD patient records: https://www.ecfr.gov/current/title-42/part-2
• K.S.A. 65-4971 — Copies of health care records; fees (subsection (b) cap repealed 2011): https://ksrevisor.gov/statutes/ksa_ch65.html
• K.S.A. 65-5601 et seq. — Treatment records of mentally ill persons: https://ksrevisor.gov/statutes/ksa_ch65.html
• K.S.A. 65-6001 et seq. — HIV/AIDS test results; confidentiality: https://ksrevisor.gov/statutes/ksa_ch65.html